LAKESHORE REGIONAL ENTITY Speech, Hearing, and Language/Occupational Therapy/Physical Therapy This service must be provided consistent with requirements outlined in the MDHHS Medicaid Provider Manual as updated. The manual is available at: http://www.mdch.state.mi.us/dch-medicaid/manuals/medicaidprovidermanual.pdf 1. Definition or Description of Service a. Speech, Hearing and Language i. Evaluation: Activities provided by a licensed speech-language pathologist or licensed audiologist to determine the beneficiary's need for services and to recommend a course of treatment. A speech-language pathology assistant may not complete evaluations. ii. Therapy: Diagnostic, screening, preventive, or corrective services provided on an individual or group basis, as appropriate, when referred by a physician (MD, DO). Therapy must be reasonable, medically necessary and anticipated to result in an improvement and/or elimination of the stated problem within a reasonable amount of time. An example of medically necessary therapy is when the treatment is required due to a recent change in the beneficiary s medical or functional status affecting speech, and the beneficiary would experience a reduction in medical or functional status were the therapy not provided. Speech therapy must be skilled (i.e., requires the skills, knowledge, and education of a licensed speech language pathologist) to assess the beneficiary s speech/language function, develop a treatment program, and provide therapy. Interventions that could be expected to be provided by another entity (e.g., teacher, registered nurse, licensed physical therapist, licensed occupational therapist, family member, or caregiver) would not be considered as a Medicaid cost under this coverage. Services may be provided by a licensed speech-language pathologist or licensed audiologist or by a speech pathology or audiology candidate (i.e., in his clinical fellowship year or having completed all requirements but has not obtained a license). All documentation by the candidate must be reviewed and signed by the appropriately licensed supervising speech-language pathologist or audiologist. b. Occupational Therapy i. Evaluation: Physician/licensed physician assistant/family nurse practitioner - prescribed activities provided by an occupational therapist licensed by the State of Michigan to determine the beneficiary's need for services and to recommend a course of treatment. An occupational therapy assistant may not complete evaluations. ii. It is anticipated that therapy will result in a functional improvement that is significant to the Individual s ability to perform daily living tasks appropriate to his chronological developmental or functional status. These functional improvements should be able to be achieved in a reasonable amount of time and should be durable (i.e., maintainable). Therapy to make changes in components of function that do not have an impact on the beneficiary s ability to perform age-appropriate tasks is not covered. Therapy must be skilled (requiring the skills, knowledge, and education of a licensed occupational therapist). Interventions that could be expected to be provided by another entity (e.g., teacher, registered nurse, licensed physical therapist, family member, or caregiver) would not be considered as a Medicaid cost under this coverage iii. Services must be prescribed by a physician/licensed physician s assistant/family nurse practitioner and may be provided on an individual or group basis by an occupational therapist or occupational therapy assistant, licensed by the State of Michigan or by an occupational therapy aide who has received on-the-job training. Interventions that Page 1 of 5
could be expected to be provided by another entity (e.g., teacher, registered nurse, licensed physical therapist, family member, or caregiver) would not be considered as a Medicaid cost under this coverage. Services must be prescribed by a physician/licensed physician s assistant/family nurse practitioner and may be provided on an individual or group basis by an occupational therapist or occupational therapy assistant, licensed by the State of Michigan or by an occupational therapy aide who has received on-the-job training. The occupational therapist must supervise and monitor the assistant s performance with continuous assessment of the beneficiary s progress, but on-site supervision of an assistant is not required. An aide performing an occupational therapy service must be directly supervised by a qualified occupational therapist who is on site. All documentation by an occupational therapy assistant or aide must be reviewed and signed by the appropriately credentialed supervising occupational therapist. c. Physical Therapy i. Evaluation - Physician/licensed physician s assistant-prescribed activities provided by a physical therapist currently licensed by the State of Michigan to determine the beneficiary s need for services and to recommend a course of treatment. A physical therapy assistant may not complete an evaluation. ii. Therapy - It is anticipated that therapy will result in a functional improvement that is significant to the beneficiary s ability to perform daily living tasks appropriate to his/her chronological, developmental or functional status. These functional improvements should be able to be achieved in a reasonable amount of time and should be durable (i.e., maintainable). Therapy to make changes in components of function that do not have an impact on the beneficiary s ability to perform age-appropriate tasks is not covered. Physical therapy must be skilled (it requires the skills, knowledge, and education of a licensed physical therapist). Interventions that could be expected to be provided by another entity (e.g., teacher, registered nurse, licensed occupational therapist, family member or caregiver) would not be considered as a Medicaid cost under this coverage. Services must be prescribed by a physician/licensed physician s assistant and may be provided on an individual or group basis by a physical therapist or a physical therapy assistant currently licensed by the State of Michigan, or a physical therapy aide who is receiving on-the-job training. The physical therapist must supervise and monitor the assistant's performance with continuous assessment of the beneficiary's progress. On-site supervision of an assistant is not required. An aide performing a physical therapy service must be directly supervised by a physical therapist that is onsite. All documentation by a physical therapy assistant or aide must be reviewed and signed by the appropriately credentialed supervising physical therapist. 2. Practice Principles a. Therapy must be reasonable, medically necessary and anticipated to result in an improvement and/or elimination of the stated problem within a reasonable amount of time. An example of medically necessary therapy is when the treatment is required due to a recent change in the Individual s medical or functional status affecting speech, and the Individual would experience a reduction in medical or functional status were the therapy not provided. b. Providers are encouraged to offer evidence-based and promising practices as part of the Medicaid covered specialty services where applicable. Providers shall assure that these practices are provided by staff who have been appropriately trained in the model(s) and are provided to the population for which the model was intended. c. Provider will be in compliance with the principles of person-centered planning as outlined in the MDHHS BHDDA Person-Centered Planning Policy. d. MDHHS encourages the use of natural supports to assist in meeting an Individual's needs to the extent that the family or friends who provide the natural supports are willing and able to provide Page 2 of 5
this assistance. The use of natural supports must be documented in the Individual's individual plan of service (IPOS). 3. Credentialing Requirements Refer to current Medicaid Provider Manual for updated requirements a. Provider will assure that licensed professional staff licensed and/or registered in the State of Michigan to provide services at the level authorized by the Payor. Licensed professionals shall act within the scope of practice defined by their license. b. Provider shall assure that all staff providing services are qualified and trained to provide services at the level authorized by the Payor. c. Provider shall ensure that all vehicles used for transporting the Individual(s) under this agreement are in safe operating condition and contain first aid equipment. d. Provider shall permit only responsible staff with an appropriate valid driver's license and insurance, as required by State law, to operate motor vehicles while transporting Individual(s) as evidenced by annual driving record and insurance checks. e. Provider shall maintain a copy of training records for each staff person for review if requested by the Payor, the LRE, or an external review team. f. Providers of services must: i. Be at least 18 years of age. ii. Be able to prevent transmission of any communicable disease from self to others in the environment where they are providing supports. iii. Be able to communicate expressively and receptively in order to follow individual plan requirements and Individual-specific emergency procedures, and report on activities performed. Understanding and skill must be documented. iv. Be in good standing with the law as outlined in the MDHHS/PIHP contract. v. Be able to perform basic first aid and emergency procedures. 4. Service Requirements a. Provider s supports and services will be based upon the Individual s IPOS, and in coordination with any additional plans of the Individual (e.g. nursing, occupational therapy, physical therapy, behavior support plans). Said documents are to be present (hard copy or electronically) at the service site, and accessible to the Provider s staff responsible for delivering the supports and services. b. Provider shall notify the Individual s care manager when the Individual s IPOS requires revision or modification. c. Provider shall provide services in the least restrictive and most integrated settings, unless the less restrictive levels of treatment, service or support have been unsuccessful or cannot be safely provided for that Individual. d. Provider shall ensure coordination of care occurs between the Individual s primary health care physician and Medicaid Health Plan (as appropriate). Coordination of care shall include the full array of primary and acute physical health services, behavioral health care, natural or community supports to provide effective treatment, and as specified in an Individual s plan of service. e. Provider shall ensure language interpretation, translation services, and hearing interpreter services are provided as needed, and at no cost to the Individual. Provider shall be responsive to the particular needs of Individuals with sensory or mobility impairments, and provide necessary accommodations. f. Provider shall complete service documentation and records that meet the PIHP/CMHSP s requirements for reimbursement. Provider s services and documentation/records shall comply with the standards of the PIHP, CMHSP, accreditation bodies, MDHHS, any applicable licensing Department or Agency of the State of Michigan, Medicaid and Medicare regulations and/or any third-party payers. Page 3 of 5
g. The Individual s record must contain sufficient information to document the provision of services, including the nature of the service, the date, and the location of contacts, including whether the contacts were face-to-face. The frequency and scope of contacts must take into consideration the health and safety needs of the Individual. h. Speech/Language/Hearing specific i. Speech-language pathologist will: (1) Evaluate Individuals receiving CMHSP services in areas of functional communication modes, language usage, functional communication skills, etc. Assessment will include but not be limited to the following information: (a) Evaluation of speech deficit/skills. (b) Assessment of ability to use augmentative communication. (c) Swallowing dysfunctions. (2) Provide speech therapy services for Individuals on a scheduled basis. (3) Provide consultation and training to the assigned Individual s interdisciplinary team. i. Physical Therapy Specific i. Services must be prescribed by a physician/licensed physician s assistant and may be provided on an individual or group basis by a physical therapist or physical therapy assistant currently licensed by the State of Michigan, or a physical therapy aide who is receiving on-the-job training. ii. The physical therapist must supervise and monitor the assistant s performance with continuous assessment of the beneficiary s progress. On-site supervision of an assistant is not required. iii. An aide performing a physical therapy service must be directly supervised by a physical therapist that is on-site. iv. All documentation by a physical therapy assistant or aide must be reviewed and signed by the appropriately credentialed supervising physical therapist. j. Occupational Therapy Specific i. Services must be prescribed by a physician/licensed physician s assistant and may be provided on an individual or group basis by an occupational therapist or physical therapy assistant currently licensed by the State of Michigan, or a physical therapy aide who is receiving on-the-job training. ii. The occupational therapist must supervise and monitor the assistant s performance with continuous assessment of the beneficiary s progress. On-site supervision of an assistant is not required. iii. An aide performing an occupational therapy service must be directly supervised by an occupational therapist that is on-site. iv. All documentation by an occupational therapy assistant or aide must be reviewed and signed by the appropriately credentialed supervising occupational therapist. k. Services shall be provided at the frequency and duration identified in the IPOS of each Individual served. Services may include: l. Provide an annual written comprehensive evaluation and recommendations for the Individuals, as assigned by CMHSP. m. Provide written outcome-based, person-centered program plans based upon the comprehensive evaluation to increase and/or to maintain current levels of speech and language skills. n. Provide in-service training to CMHSP s staff, and/or families and Provider staff on how to effectively implement therapy skills. o. Monitor service Providers and family's ability to carry out therapy programs and data/documentation as required by the IPOS. Report findings to staff, family, Director or designee and Supports Coordinator and Supports Coordinator/Case Manager and home supervisor. Provide additional in-service training as needed to ensure families and service Page 4 of 5
Providers are sufficiently trained to carry out the Individual s speech and language therapy program plans. p. Provide or recommend equipment or materials needed to improve or maintain skills to assigned Individuals. q. Provide all materials required for evaluations and/or on-going therapy. 5. Training Requirements a. See Attachment I: Training Requirements for specific training requirements and frequency of trainings. b. Provider will ensure and document that each staff is trained on the Individual s IPOS and ancillary plans, prior to delivery of service. 6. Eligibility Criteria/Access Requirements/Authorization Procedures a. Individuals presenting for mental health services will be engaged in a person-centered planning process through which diagnostic information and service eligibility will be determined. Eligibility tools may be used in conjunction with the person-centered planning process to determine and document medical/clinical necessity for the requested service. b. Waiver eligibility requires verification of no change in waiver status. c. The Lakeshore Region Guide to Services provides a summary of service eligibility, access to services, and service authorization. This document is located on the Lakeshore Regional Entity website at www.lsre.org. Additional information related to policies, procedures and Provider Manuals may be found by accessing the specific CMHSP websites. Page 5 of 5